D-52572-2012

AutoFlow®
Incorporates the benefits of free breathing
into volume controlled ventilation

Thomas Peyn
Frans Rutten
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES
Foreword

Dear reader,

Sometimes the small things make a big difference. For example, seat belts
are now standard in automobiles and have saved thousands of lives. However,
what would your reaction be as a passenger if a seat belt was only available
for the driver? Not only would such a solution be unfair, but it would be far
less successful.

Comparable examples where safety and patient comfort have been improved
can be found in the history of ventilation. However, as indicated in the above
example, such solutions should be as widely available as possible. With regard
to Dräger ventilators, this means that most products provide Autoflow as an
adjunct to volume controlled ventilation modes.

This booklet provides background information on Autoflow because

even though it is as easy to use as a safety belt, it still must be operated
by a knowledgeable user. It would greatly please the authors if this booklet
supports your use of AutoFlow to improve safety and patient comfort
in your daily routine.

We hope you enjoy reading the following!

Thomas Peyn
Lübeck, Germany

October 2012
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

Editor
Dräger Medical GmbH
Moislinger Allee 53–55
D-23542 Lübeck
www.draeger.com

Important notes

Medical knowledge is subject to constant change due to research and clinical

experience. The authors of this publication have taken utmost care to ensure that
all information provided, in particular concerning applications and effects, is current
at the time of publication. This does not, however, absolve readers of the obligation
to take clinical measures based on their own medical knowledge and judgment.
The use of registered names, trademarks, etc. in this publication does not imply,
even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations. Dräger Medical GmbH reserves all rights,
especially the right of reproduction and distribution. No part of this publication may
be reproduced or stored in any form by mechanical, electronic or photographic
means without the prior written permission of Dräger Medical GmbH.
 04 05

CONTENTS

1. What is AutoFlow? 6
2. How is AutoFlow set up? 7
3. What happens when AutoFlow is activated? 8
4. How are spontaneous efforts mixed with mandatory
volume controlled strokes? 10
5. How does AutoFlow compare to PC-BIPAP/PC-SIMV+*? 12
6. How does AutoFlow work with VC-CMV and VC? 13
7. How does AutoFlow work with VC-SIMV? 14
8. What advantages are observed when using AutoFlow? 15
9. How do leaks (e.g. in NIV) affect AutoFlow? 16
10. When can AutoFlow be used? 18
11. What monitoring parameters are important
to observe when using AutoFlow? 20
12. What safeguards are there against hypo/hyperventilation? 22
13. What is the value of AutoFlow in patients with head injury or stroke? 23
14. What is the value of AutoFlow after return
of spontaneous circulation (ROSC)? 24
15. What is the value of AutoFlow in blunt thoracic trauma? 25
16. What is the value of AutoFlow in patients who are ventilated
via a supraglottic airway? 26
Abbreviations 27
Summary 29

Explanatory notes:
In some regions of the world VC-CMV mode of ventilation is referred to as IPPV.
IPPV Assist is identical to VC-AC. The mode BIPAP* is referred to as PC-SIMV+
in the USA and Canada. AutoFlow® is a registered trademark of Dräger Medical GmbH

* trademark used under license

 AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

1. What is AutoFlow?

AutoFlow is an adjunct to volume controlled ventilation mode, it automatically

regulates inspiratory flow and inspiratory pressure. When AutoFlow is activated
the inspiratory flow pattern changes from the constant flow typical of volume
controlled ventilation to a decelerating flow pattern usually associated with
pressure controlled ventilation.

AutoFlow
– Is available in all volume controlled modes such as
VC-CMV, VC-AC, VC-SIMV, VC-SIMV/PS.
– Delivers the set tidal volume at the lowest possible inspiratory pressure.
– Reduces peak airway pressures.
– Allows the patient to breathe any time in the respiratory cycle.

Flow

Volume Controlled Switch-on AutoFlow®

VT VT
D-19845-2015

Fixed flow pattern versus decelerating flow pattern delivering identical tidal volume.
 06 07

2. How is AutoFlow set up?

AutoFlow is an adjunct to volume controlled ventilation mode. It is found

in the “settings” or “Additional settings” menu. Once the function has been
selected it is switched on by pressing the rotary knob.

There is no need to change other settings or alarm limits once AutoFlow

is activated as long as they meet clinical needs. Nevertheless, Paw high alarm
or Pmax setting have an additional function during AutoFlow: they actively
limit the range of the inspiratory pressure control. For more details please
see the corresponding Instructions for Use.

Please note: AutoFlow is only available in volume controlled modes.

D-52573-2012
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

3. What happens when AutoFlow is activated?

Once AutoFlow is activated the next mandatory ventilation stroke is delivered

with the minimal flow required to deliver the set volume within the set
inspiratory time. The resulting end inspiratory pressure is used as the
inspiratory pressure for the next breath.

Subsequently a decelerating inspiratory flow profile is used. Once expiration

begins delivered (inspiratory) volume is compared to the set tidal volume.
The inspiratory pressure of the next mandatory stroke is adjusted, up or
down, according to the measured inspiratory volume of the previous breath.

The inspiratory pressure is adjusted by a maximum of plus or minus 3 mbar

per breath. Depending on the operating philosophy the inspiratory pressure
will not exceed the set Pmax or is limited to a pressure 5 mbar below the
upper airway pressure alarm limit (Oxylog 3000plus Pmax setting minus
5 mbar). If the tidal volume can no longer be achieved, a tidal volume low
alarm is generated and a corresponding message is displayed.

Spontaneous breathing may cause fluctuations in the tidal volume, however,

AutoFlow ensures a constant tidal volume is applied, on average, over time.

It is always possible and useful to use AutoFlow provided there are

no specific pulmonary restrictions and the patient is receiving volume
controlled ventilation.
 08 09

Pressure

Volume Controlled Switch-on AutoFlow Compliance improvement

Pinsp
D-9566-2009
 AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

4. How are spontaneous efforts mixed with

mandatory volume controlled strokes?

Traditionally in volume controlled modes the ventilator closes the expiratory

and opens the inspiratory valve for a defined period of time. After the gas has
been delivered a pause (plateau) may occur and both valves are closed before
the expiratory valve opens to enable expiration. Generally the ventilator does
not respond to spontaneous efforts during such a mandatory stroke. High or
low airway pressure alarms may be seen and are obvious indicators that the
patient is fighting the ventilator.

Volume Control without Autoflow

controlled patient activity

Paw

Flow
fixed
flow
inspiration
closed
in

ex
expiration
closed t
D-9567-2009

Patient activity without AutoFlow®

 10 11

Several technical requirements have to be met to improve breathing

comfort and reduce the invasiveness of mechanical ventilation: apart
from the need to have a fast gas delivery system to meet additional flow
requirements it is also necessary for the expiratory valve to respond
immediately in case of pressure rises. This “Room to Breathe” concept
was realized in the pressure controlled PC-BIPAP/PC-SIMV+ mode for
the very first time. AutoFlow incorporates the same “Room to Breathe”
principles as PC-BIPAP/PC-SIMV+, enabling spontaneous breathing
throughout the respiratory cycle which facilitates stress-free volume
controlled ventilation.

Volume Control without Autoflow

controlled patient activity

Patient
in

ex
t

Paw

Flow

inspiration
open
in

ex
expiration
open t
D-9568-2009

Patient activity with AutoFlow®

 AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

5. H
 ow does AutoFlow compare
to PC-BIPAP/PC-SIMV+?

Volume controlled ventilation with AutoFlow and PC-BIPAP/PC-SIMV+ both

facilitate the “Room to Breathe” concept and allow the patient to breathe
spontaneously at any time in the respiratory cycle.

PC-BIPAP/PC-SIMV+ is a pressure controlled mode and the tidal volume (VT)

provided results from the pressure difference between inspiratory (Pinsp)
and expiratory (PEEP) pressure. Changes in lung compliance during
PC-BIPAP/PC-SIMV+ cause changes in tidal volume.

AutoFlow follows a different strategy: As tidal volume is the primary parameter

in volume controlled ventilation, changes in lung compliance conditions
cause changes in the inspiratory pressure (while the volume remains stable).
This is how AutoFlow supports volume protective strategies.

PC-BIPAP/PC-SIMV+ VC-SIMV/AutoFlow

Pressure & Trigger PEEP PEEP

Pinsp –
Pressure Support Pressure Support
Trigger Trigger

Time RR RR
Ti or I:E Ti or I:E
Slope Slope

Volume – VT
D-9569-2009

Key settings in PC-BIPAP/PC-SIMV+ and VC-SIMV / AutoFlow®

 12 13

6. How does AutoFlow work with VC-CMV

and VC-AC?

VC-CMV is a volume controlled mode and does not respond to patient effort.
With VC-AC the patient can trigger additional mandatory strokes.

AutoFlow does not change the cycling characteristic of any mode and
ventilation can be conducted as usual. When the patient starts making
spontaneous breathing efforts AutoFlow increases or decreases the gas flow
according to these efforts. Such an improvement in synchrony can reduce
the frequency of airway pressure alarms and increase breathing comfort
dramatically.
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

7. How does AutoFlow work with VC-SIMV?

VC-SIMV can be used on patients with spontaneous breathing. Settings

of VC-SIMV can be combined with Pressure Support and set mandatory
strokes are synchronized to spontaneous efforts.

AutoFlow automatically regulates inspiratory flow and inspiratory pressure

during the mandatory strokes. AutoFlow can improve breathing comfort,
especially if spontaneous breathing interacts with mandatory strokes.
In such a case AutoFlow provides gas flow according to the patient’s needs
and prevents from being starved of air. The level of Pressure Support is
not affected by AutoFlow and remains just as with conventional volume
controlled ventilation.

In VC-SIMV/PS the total minute volume results from set volume (RR x VT)
plus spontaneous volumes.
 14 15

8. What advantages are observed

when using AutoFlow?

Patients who have to be treated and ventilated often have spontaneous

breathing efforts. Many healthcare providers prefer to ventilate patients
in a volume controlled mode to ensure that the patient gets the tidal
volume they need, especially in hectic situations where continuous control
of the ventilator is not always possible. AutoFlow allows volume controlled
ventilation to accept spontaneous breathing of the patient.

Deep sedation should be avoided as it may result in serious complications

due to negative hemodynamic effects and reduced clinical (neurologic)
control of the patient. AutoFlow makes it possible to ventilate patients in
a volume controlled mode in situations where deep sedation or muscle
relaxation of the patient to depress spontaneous breathing is not required.
Spontaneous breathing contributes to better gas exchange and secretion
clearance.

Greater comfort and less stress for patients should in turn reduce stress
for medical staff.

Lower airway pressure results in a lower intra-thoracic pressure which has

a positive effect on hemodynamics, as well as lowering intracranial pressure
and reducing the chance of a (tension) pneumothorax.

Finally, the need to adjust fewer controls and reduced alarm management
requirements are seen as beneficiary in especially hectic situations.

Summary: AutoFlow minimizes airway pressures while ensuring

a pre-selected tidal volume delivery providing improved safety.
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

9. H
 ow do leaks (e.g. in non-invasive ventilation (NIV))
affect AutoFlow?

Leaks often occur during mask ventilation and are compensated for
by an additional gas flow from the ventilator. Pressure controlled modes
automatically detect the drop in pressure caused by a leak and react to
maintain the set pressure level.

AutoFlow enables non-invasive ventilation (NIV) to be applied in volume

controlled modes and can help to increase patient compliance. When
patients are ventilated with a mask the airway is not protected and gastric
insufflation and subsequent aspiration of gastric contents may occur.
This risk can be reduced when airway pressures are kept below
20 mbar/cmH20.

When using AutoFlow in volume modes, a sudden increase in resistance

(e.g. airway obstruction) does not result in a sudden rise in airway pressure;
instead the inspiratory pressure is adjusted to a maximum of 3 mbar/cmH20
breath to breath. The maximum inspiratory pressure in AutoFlow is limited
by Pmax or Paw high alarm as described before (please refer to question no. 3).

When AutoFlow is used, changes in inspiratory pressure may be seen

from breath to breath. Reasons for such pressure adaptations can be
lung compliance changes, patient efforts as well as variations in leaks.
If clinical circumstances require stable pressure conditions or leaks vary
widely, pressure controlled modes are a preferred ventilation strategy.
MT-14059-2010
16
17
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

10. When can AutoFlow be used?

Indications and contra indications of AutoFlow are based on the limitations

of volume controlled modes. Independent from the AutoFlow function
volume controlled ventilation may not be indicated where there is a risk
of intrinsic PEEP and the associated danger of overinflating the lung in
volume controlled strategy. This applies especially if obstructive disorders
are present or long inspiration times and relatively short expiration times
(inverse ratio) are required. In these cases pressure controlled modes like
PC-BIPAP/PC-SIMV+ are preferred because of stable pressure conditions
and an improved intra pulmonary gas distribution. Pure pressure controlled
modes are also favored in patients with uncuffed tubes or in adult patients
with significant and varying leaks.

Volume controlled modes combined with AutoFlow are indicated when­

ever the volume applied should remain stable and changes in inspiratory
pressure (as typical for any volume controlled mode) are tolerable. In terms
of patient types there are those with quite variable compliance levels e.g.
after open chest surgery or due to re-positioning. Here a volume controlled
mode combined with AutoFlow is easier to handle than pressure controlled
ventilation where careful manipulation of pressure levels is considered
necessary to keep the volume stable and to prevent hyper- or hypoventilation.

Emergency patients tend to have spontaneous breathing efforts, continuously

or during painful or stressful events. This often results in reduced synchrony
with the ventilator causing high or low airway pressures, which in turn can
result in serious side effects such as increased intracranial pressure, reduced
oxygenation, worsening of hemodynamics, etc. AutoFlow combines volume
controlled modes with the possibility of synchronization of the ventilator to the
patient’s breathing efforts, resulting in fewer side effects as mentioned above.
 18 19

Finally, AutoFlow is suitable for all start up ventilation therapy scenarios

where there is limited information on disease status available and it is
important to get therapy underway where pressures and flow are regulated
and spontaneous activity is not compromised.

Summary: Volume or pressure ventilation strategy has to be selected

according to the specific lung disease.
D-11082-2011
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

11. W
 hat monitoring parameters are important
to observe when using AutoFlow?

All monitoring used in regular volume controlled modes is also of importance

when using AutoFlow. The set tidal volume has to be adjusted on a regular
basis according to the patient’s needs, most often following arterial blood
gases (ABGs) or according to the end-tidal CO2.

For patient safety, all alarm limits have to be set and should match the
current clinical conditions. Pulmonary changes as well as spontaneous
breathing activities should be observed and monitored carefully. Spontaneous
breathing activity can be seen on the flow curve or on the capnogram.
No high Paw alarm will activate on active expiration. In addition, resistance
and compliance changes affect ventilation pressures and flow curves.

In activating AutoFlow the peak pressure will decrease as flow decelerates.

Pinsp will adjust when compliance alters. As a result mean airway pressure
will follow accordingly. The tidal volume applied may vary slightly but
the average volume equals set tidal volume. Therefore changes in airway
resistances are not seen in the pressure curve but influence the flow pattern
significantly when AutoFlow is active. If airway resistances increase it will
take longer to apply and to release a certain amount of volume.
 20 21

Peak pressure No Paw high

decreases with alarm on
decelerating spontaneous
flow breathing

Pinsp adjusts
to compliance

Paw
Paw

Pinsp. = f (V T,C)

PEEP
t

TI TE
1
f
Flow
VT

without spontaneous breathing with spontaneous breathing

Trends give Spontaneous

best overview breathing
activity seen
on flow curve
D-9570-2009

If the VT is not delivered a VT low alarm or MV low alarm is generated.

AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

12. W
 hat safeguards are there against
hypo/hyperventilation?

As in all ventilation modes Minute Volume High and Low alarms are
obligatory to ensure that the patient is adequately ventilated. In case of
triggered modes the respiratory rate is monitored by the High Respiratory
Rate alarm. The High Airway Pressure alarm warns in case of extreme
coughing or obstruction.

In addition AutoFlow offers the following three safeguards:

– If the VT that is supplied to the patient exceeds the set VT high alarm limit
(Oxylog 3000plus set VT plus 30 %), the inspiratory phase is automatically
terminated. This prevents too high a VT being delivered, in case of, for
example, a rapid increase in compliance.
– Rapid triggering by the patient does not lead to hyperventilation in the
modes VC-SIMV/AF and VC-CMV/AF. If hyperventilation occurs in the mode
VC-AC/AF the trigger can be turned off. In that case the patient is still able
to breathe spontaneously.
– If lung compliance changes, AutoFlow adjusts the inspiratory pressure,
breath by breath, by a maximum of 3 mbar/cmH20 per breath. The inspira­
tory pressure will not exceed the set Pmax or is limited to a pressure 5 mbar
below the upper airway pressure alarm limit (Oxylog 3000plus Pmax setting
minus 5 mbar). If the set VT cannot be reached due to this pressure limit,
a tidal volume low alarm and an alarm message will occur.
 22 23

13. W
 hat is the value of AutoFlow in patients
with head injury or stroke?

In patients with head injury or stroke it is of utmost importance to prevent

secondary brain damage due to hypoxia, hypoperfusion or increased intra-
cranial pressure (ICP). When these patients are unconscious (Glasgow
Coma Scale 8 or below), there is an indication for endotracheal intubation
and ventilation.

In volume controlled ventilation PaCO2 levels are maintained, which is

important in preventing additional brain injury. However, in case of volume
controlled ventilation without AutoFlow, there is a risk that the patient has
spontaneous breaths, which can cause high airway pressures, followed by
high intrathoracic pressures and possibly followed by high intra-cranial
pressures, which should be avoided at all times.

Furthermore, when the patient has pulmonary injury in combination with

head injury, the airway pressures should be maintained as low as possible
for the same reasons.

AutoFlow could be applied to patients with head injury or stroke who are
ventilated in a volume controlled mode because the airway pressures will
be as low as possible and spontaneous breathing of the patient is possible
without the rise in airway pressure.

Finally, when AutoFlow is used, there is less need for deep sedation, which
improves neurologic control of the case of patients with head injury or stroke
and has fewer negative circulatory side effects.
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

14. W
 hat is the value of AutoFlow after return
of spontaneous circulation (ROSC)?

In the period after ROSC (after CPR), the patient’s circulation is very fragile
and therefore ventilation should be performed carefully. Because there
is evidence that manual (bag) ventilation may cause hyperventilation with
a worse outcome, mechanical ventilation is recommended for better control
of ventilation and prevention of hyperventilation and high airway pressures.

Especially during this phase, AutoFlow could help to avoid the above
mentioned side effects and might help to improve outcome after ROSC.
 24 25

15. W
 hat is the value of AutoFlow in blunt
thoracic trauma?

These patients are at high risk of developing acute lung injury or ARDS
and ventilator associated complications. Airway pressures should be kept
low in thoracic trauma to avoid increasing a pneumothorax even leading
to a tension pneumothorax.

Also, in case of a pulmonary contusion, improvement of outcome can

be achieved when spontaneous ventilation can be maintained.

For these reasons, AutoFlow can be applied when patients with thoracic
trauma have to be ventilated in a volume controlled mode.
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

16. W
 hat is the value of AutoFlow in patients who
are ventilated via a supraglottic airway?

The number of patients that are ventilated via a supraglottic airway

(LMALaryngeal Mask Airway, Larynxtube etc.) is increasing in Emergency
Care OR or ICU. A supraglottic airway does not totally secure the airway but
it is recognized as the second best step when endotracheal intubation is not
possible or fails. When higher airway pressures are used, there is a risk of
leakage around the cuff and gastric insufflation may occur.

In case of mechanical ventilation in a volume controlled mode, AutoFlow can

be used as it enables control of airway pressures and spontaneous breathing
is possible without excessive airway pressures which would cause the patient
to “fight the ventilator”.
 26 27

Abbreviations

ABG arterial blood gases

AF AutoFlow

ARDS Acute respiratory distress syndrome

CPR Cardiopulmonary resuscitation

ICP intracranial pressure

NIV Non-invasive ventilation

Paw Airway pressure

PC-BIPAP Pressure Controlled – Biphasic Positive Airway Pressure

PC-SIMV+ Pressure Controlled – Synchronized Intermittent

Mandatory Ventilation

PEEP Positive End Expiratory Pressure

Pinsp Inspiratory pressure

Pmax Maximum allowed inspiratory pressure

ROSC Return of Spontaneous Circulation

SIMV Synchronized Intermittent Mandatory Ventilation

VC-AC Volume Controlled – Assist Control

VC-CMV Volume Controlled – Controlled Mandatory Ventilation

VC-SIMV Volume Controlled – Synchronized Intermittent

Mandatory Ventilation

VC-SIMV/PS Volume Controlled – Synchronized Intermittent Mandatory

Ventilation-Pressure Support

VT Tidal volume
AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES
 28 29

Summary

Benefits of Autoflow:

– Delivers set volume at lowest possible pressure in all volume modes

(Question 1, page 8)

– Reduces peak airway pressures (Question 1, page 8 & Question 11, page 22)

– Enables spontaneous breathing at anytime in all volume controlled modes

(Question 1, page 8, Question 4, page 13)

– Reduces the invasiveness of mechanical ventilation and (Question 4, page 12)

– Carries over benefits of PC-BIPAP/PC-SIMV+ to volume controlled modes

(Question 4 & 5, page 12 to 14)

– Keeps the tidal volume stable even if lung compliance changes

(Question 5, page 14 & Question 11, page 22)

– Can support volume protective strategies (Question 5, page 14)

– Prevents annoying alarms (Question 6, page 15 & Question 8, page 17)

– Improves synchrony between patient and ventilator (Question 6, page 15)

– Improves patient comfort (Question 6, page 15 & Question 7, page 16)

– Adapts flow to the patient’s needs (Question 7, page 16)

 AUTOFLOW® – AVAILABLE IN ALL VOLUME CONTROLLED MODES

Summary

– Helps to reduce patient and caregiver stress (Question 8, page 17)

– Enables less management of ventilation controls (Question 8, page 17)

– Supports the care giver by helping them to keep control of hectic situations
(Question 8, page 17)

– Enables low sedation (Question 8, page 17 & Question 13, page 25)

– Recognizes leaks and compensates to a certain level (Question 9, page 18)

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